DIVISION OF MEDICAL QUALITY ASSURANCE - Florida ...

DIVISION OF MEDICAL QUALITY ASSURANCE Enforcement Program

Health care practitioners are regulated by the Department of Health and the action which may be taken is administrative in nature, e.g., reprimand, fine, restriction of practice, remedial education, administrative cost, probation, license suspension or license revocation. The Department cannot represent you in civil matters to recover fees paid or seek remedies for injuries. You may wish to consult a private attorney regarding these matters.

The Department of Health investigates complaints and reports involving health care practitioners and enforces appropriate Florida Statutes.

ISSUES WHICH ARE NOT WITHIN THE AUTHORITY OF THE DEPARTMENT INCLUDE:

Fee disputes (i.e. broken or missed appointments) Billing disputes (i.e., the amount a physician charges for services). Personality conflicts Bedside manner or rudeness of practitioners (such as the physician or his/her

office staff's attitude or professionalism)

HOW TO FILE A COMPLAINT/REPORT AGAINST A HEALTH CARE PRACTITIONER:

? To file a complaint/report, you must do so in a signed, written report. For your convenience you may use this form providing dates and details about your complaint.

? Use a separate complaint form for each practitioner you wish to file a complaint against. ? Be specific and include copies of pertinent medical records, correspondence, contracts,

and any other documents that will help support your complaint. ? Medical records are needed to process your complaint. Since a health care practitioner

cannot disclose his or her patient names or records without authorization, the Authorization for Release of Patient Information form included on page 3 must be completed and signed. Signatures must be witnessed or notarized. ? The Department will notify you in writing of the status of your complaint throughout the process. Please advise us of any address change. ? If the allegations contained in your complaint/report are determined to be possible violations of applicable laws and rules, your complaint will be opened for investigation. ? Please note that if your complaint is assigned for investigation, a copy of the complaint form will be provided to the health care practitioner pursuant to Florida law. ? The Department may investigate an anonymous complaint if the complaint is in writing and is legally sufficient, if the alleged violation of law or rules is substantial, and if the department has reason to believe, after preliminary inquiry, that the violations alleged in the complaint are true. ? If you are reporting Medicaid Fraud, you may be entitled to a reward through the Office of the Attorney General. For information and to report Medicaid Fraud, please contact the Attorney General's Fraud Hotline by calling 1-866-966-7226 or online at and clicking the "Report Fraud" button.

Division of Medical Quality Assurance, Consumer Services Unit 4052 Bald Cypress Way, Bin C-75 Tallahassee, FL 32399-3275

Telephone Number (850) 245-4339 Visit us online at

HEALTHCARE PRACTITIONER COMPLAINT FORM

COMPLAINANT/REPORTER

Your Name:

Last

First

Address:

Street Address

M.I. Apartment/Unit #

City

Home Telephone:

(

)

SUBJECT OF COMPLAINT/REPORT

Provider's Name:

Practice Address:

Last Street Address

State

Work Telephone: (

)

HEALTHCARE PRACTITIONER INFORMATION

ZIP Code

Best Time to Call:

First

M.I.

Apartment/Unit #

City

Home Telephone:

(

)

Profession:

License Number: PATIENT INFORMATION

Name of Patient:

Last

Address:

Street Address

State

ZIP Code

Work Telephone: (

)

(i.e. doctor, dentist, nurse, etc.)

(if known) (Complete this section if Patient is not the same as Complainant/Reporter)

First

M.I.

Apartment/Unit #

City

Home Telephone: (

)

YOUR RELATIONSHIP TO PATIENT

Self Parent

Son/Daughter

State

Work

Telephone:

(

)

Spouse

Brother/Sister

Friend

ZIP Code

Other Practitioner

*** Legal Guardian/provide court documents

Other

NATURE OF COMPLAINT/REPORT

(Please check all that apply.)

Quality of care

Inappropriate prescribing

Misdiagnosis of condition

Sexual contact with patient

Substance abuse

Insurance fraud

Advertising violation

Misfilled prescription

Excessive test or treatment Failure to release patient records Impairment/medical condition Patient abandonment/neglect

Unlicensed

Problem other than listed above

Have you attempted to contact the practitioner concerning your complaint? Yes Date:

No

Would you be willing to testify if this matter goes to a formal hearing? Yes

No

If the incident involved criminal conduct, you should contact your local law enforcement authority. Have you contacted your

local law enforcement authority? Yes

No

If yes, state the name of the person or office that you contacted.

When did you make

this contact?

Please give case number if available.

***NOTE: If other than patient or parent of a minor patient, please provide documentation indicating

appointment of Legal Authority/Guardianship or Personal Representative.

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PLEASE LIST ANY PRIOR AND/OR SUBSEQUENT TREATING PRACTITIONERS RELATIVE TO YOUR COMPLAINT.

Full Name:

Address:

Telephone Number:

Prior Treating Subsequent Treating

Full Name:

Address:

Telephone Number:

Prior Treating Subsequent Treating

Full Name:

Address:

Telephone Number:

Prior Treating Subsequent Treating

WITNESSES Full Name:

(PLEASE GIVE FULL NAME, ADDRESS AND TELEPHONE NUMBER)

Address:

Telephone Number:

Full Name:

Address:

Telephone Number:

Full Name:

Address:

Telephone Number:

Please give full details of your complaint/report: include facts, details, dates, locations, etc. Please attach copies of medical records, correspondence, contracts, and any other documents that will help support your complaint. (attach additional sheets if necessary).

I have attached copies of medical records, correspondence, contracts, and any other documents that will help support your complaint.

WHAT WOULD SATISFY YOUR COMPLAINT?

Florida Statutes 837.06, False Official Statements: Whoever knowingly makes a false statement in writing with the intent to mislead a public servant in the performance of his official duty shall be guilty of a misdemeanor of the second degree.

Signature:

(Required to file complaint)

Date:

Please mail this form to: Florida Department of Health Consumer Services Unit 4052 Bald Cypress Way, Bin C-75 Tallahassee, Florida 32399-3275

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Mission:

To protect, promote & improve the health of all people in Florida through integrated state, county & community efforts.

Vision: To be the Healthiest State in the Nation

Rick Scott Governor

John H. Armstrong, MD, FACS State Surgeon General & Secretary

AUTHORIZATION FOR RELEASE OF PATIENT INFORMATION TO: Any and All Treating Health Care Practitioners or Facilities: This authorization meets the requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA Privacy Law) found at 45 CFR, Part 164. A photocopy of this document is as sufficient as the original. This document authorizes any and all licensed health care practitioners, including but not limited to: physicians, nurses, therapists, social workers, counselors, dentists, chiropractors, podiatrists, optometrists, hospitals, clinics, laboratories, medical attendants and other persons who have participated in providing any health care or service to me, to discuss any communication, whether confidential or privileged, and to provide full and complete patient reports and records justifying the course of treatment including but not limited to: patient histories, x-rays, examination and test results, HIV, mental health, drug abuse treatment, psychiatric and psychological records, reports or information prepared by other persons that may be in your possession and all financial records, to the Department of Health (or any official representative of the Department) pursuant to Section 456.057, Florida Statutes. This document provides full authorization to the Department of Health (or any official representative of the Department) to use any of the aforementioned reports and information for reproduction, investigation or other use for licensure or disciplinary actions and civil, criminal or administrative proceedings, as needed by the Department and may be subject to re-disclosure by the recipient and may no longer be protected by the federal privacy laws and regulation. By signing below, the patient understands, acknowledges and authorizes the Department to release their identity and medical records to law enforcement and other regulatory agencies in appropriate circumstances at the departments' discretion. I understand that this authorization may be revoked upon my written request except to the extent that action has already been taken on this authorization. _________________________________ Patient Name (Please Print)

Patient Signature

D.O.B.

Social Security Number

Date

Name of Authorized Person other than Patient (Please Print)

Relationship

________________________________________ Signature of Authorized Person Other than Patient

STATE of ____________________

COUNTY of

Before me personally appeared

whose identity is known to me by

(type of identification) and who acknowledges that his/her signature appears above.

Sworn to or affirmed by Affiant before me this day of

, 20

NOTARY PUBLIC - State of Florida

My Commission Expires

Type or Print Name

Florida Department of Health Division of Medical Quality Assurance ? Bureau of Enforcement 4052 Bald Cypress Way, Bin C-75? Tallahassee, FL 32399-3275 PHONE: 850-245-4339 ? FAX 850-488-0796

Inv Form 390

Witness Signature (if not notarized)

DOH USE ONLY Reference Number: _______--___________

TWITTER:HealthyFLA

FACEBOOK:FLDepartmentofHealth YOUTUBE: fldoh

DENTAL QUESTIONNAIRE

PART A

COMPLAINANT: SUBJECT:

1. Has the treatment provided by the dentist been altered? If so by whom?

2. Please provide the following: (a) Sign and date the enclosed Authorization for Release of Medical Information form. Please have your signature notarized or witnessed, and return the form to this office;

(b) PATIENT RECORDS FROM THE DENTIST;

(c) Name, address, and telephone number of any previous dentist(s); PLEASE INCLUDE PATIENT RECORDS 1. Has the treatment provided by the dentist been altered? Yes/No

(d) Name, address, and telephone number of subsequent dentist(s), including current dentist; PLEASE INCLUDE PATIENT RECORDS

(e) Factual narrative from subsequent dentist(s) as to his/her clinical observation, treatment plan, and treatment provided to date;

(f) All x-rays; (from subject, previous and subsequent dentists)

(g) Chronology of your treatment rendered, including month, day and year of treatment;

(h) Detailed description of the treatment provided and the major complaint; (please use the attached chart)

PLEASE BE ADVISED THAT THE DEPARTMENT HAS NO AUTHORITY TO MANDATE A LICENSEE TO PROVIDE A REFUND. THESE MATTERS ARE CIVIL IN NATURE AND SHOULD BE ADDRESSED TO THE COURT WITH THE APPROPRIATE JURISDICTION.

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